Cervical Spine Anatomy and Clinical Evaluation Orthopedic Assessment III – Head, Spine, and Trunk with Lab PET 5609C

Clinical Anatomy Cervical Spine: Greatest range of motion ↑ risk of injury Vertebral bodies: Smaller than other vertebral sections 7 vertebrae: 1st – Atlas 2nd – Axis

Clinical Anatomy Cervical Spine: Atlas: No vertebral body Transverse processes No true spinous process Supports the weight of the skull through 2 facet surfaces (atlanto-occipital joint or C0-C1 articulation) Flexion and extension (primary movement) Lateral flexion (slight)

Clinical Anatomy Atlanto-occipital joint dislocation: (15% of all fatal spinal trauma) MOI: high speed motor accident; Pt. unconscious at the scene, respiratory arrest en route to hospital Lateral cervical spine radiograph: Prevertebral soft-tissue swelling (white arrow) Malalignment between the skull and the cervical spine with widening of the atlanto-occipital joints (black arrow)

Clinical Anatomy Cervical Spine: Axis: Atlanto-axial joint: 2nd cervical vertebrae Small body with a superior projection (Dens) Atlanto-axial joint: Dens and atlas articulation Rotation of the skull

Clinical Anatomy Cervical ligaments: Anterior and posterior longitudinal ligaments: Limit extension and flexion Ligamentum nuchae: Limits flexion Interspinous ligaments: Between spinous processes Limit flexion and rotation Ligamentum flavum: Connect laminae Limits flexion and rotation

Clinical Anatomy Brachial Plexus: C5 – T1 7 cervical vertebrae 8 cervical nerves: 1st 7: exit above the corresponding vertebrae C8: exits below the 7th cervical vertebrae

Clinical Anatomy Muscular Anatomy: Cervical extension and flexion → bilateral contraction of cervical muscles Side bending and rotation → unilateral contraction Superficial cervical musculature: Splenius capitis Splenius cervicis Upper trapezius Sternocleidomastoid

Clinical Anatomy Splenius capitis: Splenius cervicis: O: Lower half of ligamentum nuchae I: Mastoid process and adjacent occipital bone A: Lateral bending Splenius cervicis: O: C7 spinous process through T6 I: Transverse processes of C2 – C4 A: Rotation, extension

Clinical Anatomy Upper trapezius: O: Occipital protuberance, nuchal line, upper portion of ligamentum nuchae I: Lateral 1/3 of clavicle, acromion process A: Cervical extension, cervical spine bending, scapular elevation, upward scapular rotation

Clinical Anatomy Levator scapulae: O: Spinous process of C7, transverse processes of C1 through C4 I: Superior medial border of scapula A: Extension of cervical spine, scapular elevation and downward rotation

Clinical Anatomy Scalenes: Anterior scalene: Middle scalene: O: Anterior portion of transverse processes C3-C6 I: Sternal attachment of 1st rib Middle scalene: O: Anterior portion of transverse processes C2-C7 I: Lateral to insertion of anterior scalene on 1st rib Posterior scalene: O: Anterior portion of transverse processes C5-C6 I: Medial portion of 2nd rib Action: Lateral bending of cervical spine

Clinical Anatomy

Clinical Anatomy Sternocleidomastoid: O: Medial clavicular head, superior sternum I: Mastoid process A: Flexion of cervical spine, rotation to opposite side, lateral bending

Clinical Evaluation History: Location of pain: Onset of pain: Localized pain: Muscle strain, ligament sprain, vertebral fracture, facet syndrome Radiating pain: Trauma to cervical nerve root or spinal cord Onset of pain: Acute, chronic, insidious

Clinical Evaluation History: Mechanism of Injury: Insidious onset: Overuse and postural conditions Acute onset: Axial load (compression fracture) Flexion (compression of anterior vertebral body and intervertebral disc; facet joint sprain; posterior muscle strain) Extension (compression of posterior vertebral body and intervertebral disc; anterior longitudinal ligament sprain) Lateral bending (nerve root compression, facet joint compression)

Clinical Evaluation History: Mechanism of Injury: Acute onset: Rotation (disc trauma, ligament sprain, vertebral dislocation) Consistency of pain: Inflammatory induced pain: consistent pain Mechanical pain (i.e. nerve compression): varies in intensity, moving spine may ↑ or ↓ pain Previous injury Scar tissue formation Injured disc Osteophyte within intervertebral foramina

Clinical Evaluation Inspection: Cervical curvature: Lordotic curvature – normal Lateral bending posture - ↓ pressure on nerve roots away from the bend

Clinical Evaluation Inspection: Position of head on the shoulders: Unilateral spasm – lateral flexion of head towards involved side Torticollis: Wry neck Rotation of chin opposite the side of the tilt Congenital or acquired spasm of the SCM

Clinical Evaluation Inspection: Position of the head on the shoulders: Torticollis Infant with torticollis: The attitude of the head and neck results from a combination of head tilt and rotation. A tight SCM muscle causes head tilt towards the tight side with rotation of the chin to the opposite side 18 years age male with congenital torticollis with the left SCMM tight as a band unabeling him to turn his head to the right

Clinical Evaluation Inspection: Bilateral soft tissue comparison: Trapezius and other musculature: Hypertrophy, atrophy Level of the shoulders: Height of acromioclavicular joints Deltoids Clavicles

Clinical Evaluation Palpation: Anterior Structures: Hyoid bone: Have patient swallow noting superior and inferior movement Level of 3rd cervical vertebrae Thyroid cartilage: Adam’s apple Level of 4th and 5th cervical vertebrae Cricoid cartilage: Level of 6th cervical vertebrae

Clinical Evaluation Palpation: Anterior structures: Sternocleidomastoid: Have patient rotate head Scalenes: Posterior to SCM (C3-C6 level) Carotid artery Lymph nodes

Clinical Evaluation Palpation: Posterior and Lateral Structures: Occiput and superior nuchal line Transverse processes Spinous processes: Have patient flex c-spine C7 and T1 Trapezius

Clinical Evaluation Range of Motion: Active neck flexion and extension: Test position: patient can be standing or seated Motion: Atlanto-occipital joint Flexion: patient touches chin to chest (450) Extension: patient looks up towards ceiling (450) Active neck lateral flexion: Test position: patient seated or standing Patient takes ear to shoulders (450)

Clinical Evaluation Range of Motion: Active rotation: Test position: patient seated, head held upward and facing forward Patient attempts to look over each shoulder Motion: Atlanto-axial joint (450)

Clinical Evaluation Range of Motion: Passive flexion: Patient position: supine ATC: grab patient’s head (under occiput) and attempt to bring chin to chest Passive extension: Patient position: supine, head off end of table ATC: grasp patient’s head and move into extension

Clinical Evaluation Range of Motion: Passive lateral flexion: Patient position: supine, head in neutral position ATC: one hand under occiput, tilt head/neck to bring ear to shoulder Passive rotation: Patient position: supine ATC: grasp patient’s forehead and occiput, rotate head and neck

Clinical Evaluation

Clinical Evaluation Range of Motion: Resisted range of motion: Flexion Patient: supine with cervical spine and head in neutral position Stabilization: superior aspect of sternum Resistance: to the forehead Muscles tested: SCM and anterior scalenes

Clinical Evaluation Range of Motion: Resisted range of motion: Extension Patient: prone with cervical spine and head in neutral position Stabilization: superior aspect of thoracic spine Resistance: to the skull over the occiput Muscles tested: trapezius (upper 1/3, levator scapulae, cervical paraspinal muscles)

Clinical Evaluation Range of Motion: Resisted range of motion: Lateral flexion Patient: seated with cervical spine and head in neutral position Stabilization: over the AC joint on the side toward the motion Resistance: over the temporal and parietal bones on the side toward the motion Muscles tested: SCM, scalenes, paraspinal muscles on the side being tested

Clinical Evaluation Range of Motion: Resisted range of motion: Rotation Patient: seated with cervical spine and head in neutral position Stabilization: over the anterior shoulder on the side toward the rotation Resistance: over the temporal bone on the side toward the motion Muscles tested: SCM, multifidus, rotators

Clinical Evaluation C1-C2 Neck flexion C3 Neck lateral flexion C4 Shoulder shrug C5 Shoulder abduction, ER C6 Elbow flexion, wrist extension C7 Elbow extension, wrist flexion C8 Thumb extension T1 Finger abduction and adduction

Clinical Evaluation Neurological Screening: Nerve root: C5 (Biceps brachii) Patient: seated and relaxed ATC: thumb placed over biceps tendon, strike the thumb nail with reflex hammer

Clinical Evaluation Neurological Screening: Nerve root: C6 (Brachioradialis) Patient: seated and relaxed ATC: taps the brachioradialis with reflex hammer

Clinical Evaluation Neurological Screening: Nerve root: C7 (Triceps) Patient: seated and relaxed ATC: support arm in position of extension and abduction, tap the triceps tendon with reflex hammer

Clinical Evaluation Babinkski Test: Athlete:  Supine with shoes and socks removed ATC:  At the foot of the athlete holding a blunt tool Procedure:  ATC runs the tool up bottom of athlete’s foot starting at the calcaneus and ending at the great toe Positive test:  Great toe extends while other toes splay Implications:  Lesion of upper motor neurons, may be caused by trauma to the brain Comments:  This reflex occurs naturally in newborns.  However, this reflex should cease quickly after birth

Clinical Evaluation Oppenheim Test: Test: Upper motor neuron lesions Patient position: supine ATC: at patient’s side Procedure: examiner’s fingernail is run along the crest of the anteromedial tibia Positive test: great to extends and the other toes splay